Penicillin concentrations in oropharyngeal and frontal sinus tissue following enteral and intravenous administration measured by microdialysis in a porcine model.

BACKGROUND: Penicillin may be administered enterally or intravenously for the treatment of bacterial infections within the oropharynx and the frontal sinuses. We aimed to assess and compare penicillin concentrations in oropharyngeal and frontal sinus tissues following enteral and intravenous administration in a porcine model. METHOD: Twelve pigs were randomized to receive either enteral (0.8 g Penicillin V) or intravenous (1.2 g Penicillin G) penicillin. Microdialysis was used for sampling in oropharyngeal and frontal sinus tissues during a six-hour dosing interval. In addition, plasma samples were collected. The primary endpoints were time with drug concentration above the minimal inhibitory concentration (T>MIC) for two MIC targets: 0.125 (low target) and 0.5 (high target) µg/mL (covering Group A Streptococci, Fusobactarium necrophorum, Streptococcus pneumoniae and Hemophilus influenza) and attainment of these treatment targets for ≥50 % T>MIC. RESULTS: For both the low and high MIC targets, intravenous administration resulted in higher T>MIC in oropharyngeal and frontal sinus tissues compared to enteral administration. In oropharyngeal tissue, the treatment target (≥50 % T>MIC) was achieved for both the low target (96 %) and high target (68 %) when penicillin was administrated intravenously. In frontal sinus tissue, the treatment target was reached for the low target (70 %), but not the high target (35 %) when administered intravenously. None of the two tissues reached the treatment targets when penicillin was administered enterally. CONCLUSION: Intravenous administrated penicillin in standard dosage is superior to enteral administration of penicillin in standard dosage in achieving clinically important T>MIC as the majority of targets were achieved following intravenously administration, while none of the targets were achieved following enteral administration. These results support the general notion of higher tissue concentrations following intravenous compared to enteral administration.

Validity of obstructive sleep apnoea diagnoses.

INTRODUCTION: Healthcare databases are a valuable source for epidemiological research in obstructive sleep apnoea, but accurately registered diagnoses are pivotal in contributing quality evidence. We examined positive predictive values (PPV) of the International Classification of Diseases, tenth version (ICD-10) diagnosis for "obstructive sleep apnoea" and "sleep apnoea" in the Danish National Patient Register. METHODS: Using the Danish National Patient Registry, we randomly sampled 100 patients from the North Denmark Region diagnosed with "obstructive sleep apnoea" (ICD-10 code DG4732) and 100 patients diagnosed with "sleep apnoea" (DG473*) during the year 2020. We calculated the PPV using a documented Apnea-Hypopnea Index (AHI) ≥ 5 to confirm the recorded diagnosis. A total of 70 patients were referred to the private sector for assessment of the AHI and excluded due to limited access to their data. RESULTS: The study population included 130 patients, among whom 64 were diagnosed with "obstructive sleep apnoea", and 66 patients were registered with "sleep apnoea". The PPV for "obstructive sleep apnoea" was 93.8% (95% confidence interval (CI): 85.0-97.5%), and the PPV for "sleep apnoea" was 80.3% (95% CI: 69.2-88.1%). CONCLUSIONS: Our findings indicated a high validity of the ICD-10 code DG4732 with a PPV of 93.8% and a lower PPV (80.3%) for the ICD-10 code DG473* for identifying patients with obstructive sleep. The "obstructive sleep apnoea" diagnosis is a suitable source of data for epidemiological research to identify patients with the disease. FUNDING: None. TRIAL REGISTRATION: Not relevant.

Cardiovascular Risk in Young Patients Diagnosed With Obstructive Sleep Apnea.

BACKGROUND: In older adults, obstructive sleep apnea (OSA) has been associated with several cardiovascular complications. Whether young patients diagnosed with OSA also are at higher risk of developing subsequent cardiovascular disease is uncertain. We aimed to estimate the risk of developing an incident cardiovascular event among young patients diagnosed with OSA. METHODS AND RESULTS: We linked nationwide Danish health registries to identify a cohort of patients aged ≤50 years with OSA using data from 2010 through 2018. Cases without OSA from the general population were matched as controls (1:5). The main outcome was any cardiovascular event (including hypertension, diabetes, atrial fibrillation, ischemic heart disease, ischemic stroke, heart failure, and venous thromboembolism). All-cause mortality was a secondary outcome. The study included 20 240 patients aged ≤50 years with OSA (19.6% female; mean±SD age 39.9±7.7 years) and 80 314 controls. After 5-year follow-up, 31.8% of the patients with OSA developed any cardiovascular event compared with 16.5% of the controls, with a corresponding relative risk (RR) of 1.96 (95% CI, 1.90-2.02). At 5-year follow-up, 27.3% of patients with OSA developed incident hypertension compared with 15.0% of the controls (RR, 1.84 [95% CI, 1.78-1.90]). Incident diabetes occurred in 6.8% of the patients with OSA and 1.4% of controls (RR, 5.05 [95% CI, 4.60-5.54]). CONCLUSIONS: Similar to older adults, young adults with OSA demonstrate increased risk of developing cardiovascular events. To prevent cardiovascular disease progression, accumulation of cardiovascular risk factors, and mortality, risk stratification and prevention strategies should be considered for these patients.

Risk of permanent social security benefits and overview of work participation among patients with obstructive sleep apnea.

BACKGROUND: In this nationwide study, we used Danish population registries to estimate the excess risk of receiving permanent social security benefits for patients with obstructive sleep apnea (OSA) and to track their labour force participation. METHODS: We identified all Danish citizens receiving a diagnosis of OSA between 1995 and 2015. As a reference cohort, we randomly selected 10 citizens for each patient, matched by sex and birth year. Using the Fine and Gray competing risk regression, we estimated the cumulative incidences of receiving permanent social security benefits. Cox proportional hazard models were used to compare the risk of receiving permanent social security benefits in patients with OSA compared to the reference cohort. The Danish Rational Economic Agents' Model (DREAM) database was used to identify the labour market status prior to diagnosis, at time of diagnosis, and after diagnosis. RESULTS: We identified 48,168 patients with OSA. A total of 12,413 (25.8%) patients with OSA had received permanent social security benefits, compared with 75,812 (15.7%) individuals in the reference cohort. Patients with OSA had a significantly increased risk of receiving permanent social security benefits when compared with the reference cohort (hazard ratio, 1.95; 95% CI, 1.88-2.02; and subhazard ratio, 1.92; 95% CI, 1.85-1.98). Work participation was lower for OSA patients compared to references at all time-points. CONCLUSION: Patients with OSA have a moderately increased risk of receiving permanent social security benefits in Denmark after controlling for available confounders.

Obstructive sleep apnea and road traffic accidents: a Danish nationwide cohort study.

STUDY OBJECTIVES: In this nationwide study, we investigate the risk and severity of all road traffic accidents in patients with obstructive sleep apnea (OSA). METHODS: We used the unique Danish registries to identify all Danish citizens receiving a diagnosis of OSA between 1995 and 2015. As a reference cohort, we randomly selected 10 sex- and age-matched citizens for each patient. We used Poisson regression to calculate the incidens rate ratio (IRR) for all road traffic accidents (motor vehicle, bicycle, and pedestrian) in both groups, and Cox proportional regression analysis to compare risk of first motor vehicle accident. Lastly, we used Fischers' Exact test to compare severity of motor vehicle accident between the two groups- RESULTS: We identified 48,168 patients with OSA, covering up to 24 years of follow-up. Patients with OSA had an increased risk of road traffic accidents when compared with the reference cohort (hazard ratio, 1.15; 95% CI, 1.10-1.20; IRR: 1.19; 95% CI, 1.14-1.29), especially motor vehicle accidents (hazard ratio, 1.29; 95% CI, 1.18-1.39; IRR 1.30; 95% CI, 1.20-1.42). The risk of accidents as pedestrian or bicyclist were not increased. Further, patients with OSA had a tendency to be involved in more severe motor vehicle accidents. CONCLUSIONS: This is the first nationwide study to estimate the risk of all road traffic accidents in patients with OSA. Our estimates show that patients with OSA have an increased risk of motor vehicle accidents, and greater severity of accidents, when compared with a large reference cohort.

[Diagnosis and treatment of subperiosteal orbital abscess].

Subperiosteal orbital abscess is a complication of acute bacterial sinusitis. In this review, we summarise the theoretical background and highlight the importance of a fast diagnostic workup. The treatment of acute sinusitis with involvement of an eye is antibiotic therapy and daily evaluation by both an ophtalmologist and a rhinologist. In case of clinical stagnation and/or formation of an abscess, surgery is the treatment of choice.

Obstructive sleep apnea and risk of suicide and self-harm: a Danish Nationwide Cohort Study.

STUDY OBJECTIVES: In this nationwide study, we used the unique Danish registries to estimate the risk of suicide and deliberate self-harm in patients with obstructive sleep apnea (OSA). METHODS: We identified all Danish citizens receiving a diagnosis of OSA between 1995 and 2015. As a reference cohort, we randomly selected 10 citizens for each patient, matched by sex and birth year. Using the Fine and Gray competing risk regression, we estimated the cumulative incidences of suicide, and Cox proportional regression analysis was used to compare the risk of suicide and deliberate self-harm in patients with OSA with the reference cohort. RESULTS: We identified 48 168 patients with OSA. A total of 135 patients had died by suicide, compared with 999 suicides in the reference cohort. Patients with OSA had an increased risk of dying by suicide when compared with the reference cohort (hazard ratio, 1.29; 95% CI = 1.07% to 1.55%; and subhazard ratio, 1.23; 95% CI = 1.10% to 1.45%). We identified 1004 events of self-harm among patients with OSA, and 5270 events in the reference group. The overall risk of self-harm was increased in patients with OSA when compared with the reference group (hazard ratio, 1.28; 95% CI = 1.19% to 1.37%). CONCLUSIONS: This is the first study to estimate the risk of suicide and deliberate self-harm in patients with OSA. We found that patients with OSA have an increased risk of both suicide and deliberate self-harm when compared with a large reference cohort, thereby highlighting the importance of a mental health screening in these patients.

In-person versus video instruction of patients with sleep apnoea in the use of continuous positive airway pressure (CPAP).

INTRODUCTION: Instructing newly diagnosed sleep apnoea patients in the use of continuous positive airway pressure (CPAP) machines is time consuming for healthcare workers and patients alike. Our aim was to test the feasibility of video instruction as an alternative to physical attendance in the clinic. METHODS: In this randomised controlled trial, we enrolled 120 patients who were randomised to either classic instruction by a nurse or video instruction at home. Both patients and doctors answered questionnaires at the time of inclusion. Follow-up was 1-3 months. RESULTS: No significant difference was recorded between the two groups on any measured parameter. CONCLUSIONS: Video instruction is feasible and should be considered as an alternative to physical attendance for the CPAP start-up. FUNDING: none. TRIAL REGISTRATION: clinicaltrials.gov (NCT number 15022020).

Oropharyngeal rhabdomyoma: the cause of severe sleep apnoea?

This case report presents an elderly male patient who on diagnosis with a large oropharyngeal tumour had no specific symptomatology apart from severe obstructive sleep apnoea. Histopathology revealed the tumour to be an adult rhabdomyoma, a rare but benign tumour arising from striated muscle cells. The tumour obstructed most of the oropharyngeal space and almost occluded the patient's airway when lying in a supine position. The patient was deemed operable, and the tumour was excised in toto using a transoral robotic surgery system. On follow-up, the patient had a severe reduction of apnoeas/hypopnoeas and felt subjectively 'reborn'. This is to our knowledge the first case where an adult rhabdomyoma is removed using a robot-assisted approach, thus presenting a new and viable option when considering removal of benign tumours of the pharynx leading to a very minor degree of morbidity for the patients.

Bilateral dacryocystitis complicated by unilateral retrobulbar abscess in a five-week-old infant.

Retrobulbar orbital abscess in children is a rare condition, and diagnosis and management can be challenging. We report the case of a 5-week-old male infant with retrobulbar orbital abscess secondary to acute dacryocystitis developed from a dacryocystocele. The patient presented with respiratory difficulty, sepsis and progressive clinical findings suggestive of post-septal cellulitis. He was successfully treated with endonasal incision of subturbinate dacryocystoceles followed by probing of the lacrimal ducts. Congenital dacryocystocele must be considered a differential diagnosis in infants with respiratory difficulty and may develop into a vision- and life-threatening condition requiring immediate intervention.

Subjective tiredness does not correlate with the Apnoea-Hypopnoea Index.

INTRODUCTION: Sleepiness is a frequent complaint and might be a symptom of obstructive sleep apnoea. Our aim was to examine if patient-reported tiredness on either the Epworth Sleepiness Scale or on a visual analogue scale was associated with the Apnoea-Hypopnoea Index. METHODS: We conducted a retrospective database study on 215 patients referred on suspicion of obstructive sleep apnoea. Before cardiorespiratory monitoring, all patients answered the Epworth Sleepiness Scale Questionnaire and rated their tiredness on a visual analogue scale. RESULTS: No correlation was found between the Apnoea-Hypopnoea Index and the Epworth Sleepiness Scale (Spearman's ρ = 0.02) or the visual analogue scale of tiredness (ρ = -0.04). This also applied for a subgroup of patients with an Apnoea-Hypopnoea Index score > 15. CONCLUSIONS: Monosymptomatic patient-reported tiredness should not raise suspicion of obstructive sleep apnoea. Conversely, if obstructive sleep apnoea is suspected, a lack of tiredness should not postpone further evaluation. FUNDING: none. TRIAL REGISTRATION: not relevant.

Retained tooth in the nasal cavity: a rare cause of nasal congestion.

A 59-year-old man presented with unilateral nasal congestion and discharge. Clinical examination revealed a mass in the floor of the nasal cavity. Sinus CT indicated a retained tooth or a dermoid cyst. It was removed by endoscopic surgery. Histology confirmed the diagnosis of a retained tooth. At follow-up, the patient reported no nasal symptoms. A retained nasal tooth is rare, and the symptoms are variable. It can resemble other diseases such as chronic rhinosinusitis. Surgical removal is recommended to confirm the diagnosis and eliminate symptoms.

10-year-old with concha bullosa pyogenic mucocele.

A 10-year-old girl presented with episodes of migraine. A nasal mass was found randomly during work-up. Interpreted as an osteoma, the mass was removed during endoscopic surgery. However, the histopathological examination turned out to be a pyomucocele in the right middle turbinate, which is an extremely rare yet benign condition in children.

[Treatment of recurrent posterior epistaxis].

30% of the patients presenting with epistaxis at emergency wards and otorhinolaryngeal specialist departments have posterior bleeding. Traditional treatment with packing often leads to initial treatment failure, and many patients experience recurrent bleeding within the following month. Recurrent posterior epistaxis should be treated with local electrocautery or endoscopic ligation of the sphenopalatine artery to reduce patient discomfort, hospital stay, risk of treatment failure and recurrence.

Translation and validation of the Stop-Bang Questionnaire for obstructive sleep apnoea into Danish.

INTRODUCTION: Obstructive sleep apnoea (OSA) is a growing problem as more and more consequences of the condition become unveiled owing to continued research on the subject. It is essential to establish relevant, fast and accurate screening options, both in the primary sector and for preoperative screening in hospitals if we are to diagnose and treat this condition and thereby avoid the consequences of the untreated disease. METHODS: We have translated the Stop-Bang Questionnaire (SBQ) into Danish (SBQD) according to the guidelines presented by Guillemin et al in 1993. A validation study was performed including 43 consecutive patients. RESULTS: Most of the patients were men (79%). The overall median age was 54 years (range: 21-83 years). The median SBQD score for the group with an Apnoea Hypopnoea Index value (AHI) > 5 SBQD was 4 (range: 2-5), AHI > 15 SBQD score 5 (range: 4-7) and AHI > 30 SBQD score 7 (range: 4-8). Setting the SBQD cut-off at three, thereby defining scores 0-2 as normal as proposed by the authors, we observed the following sensitivity: AHI > 5 = 96.6%, AHI > 15 = 100% and AHI > 30 = 100%. The area under the curve was calculated and significant p-values achieved. CONCLUSIONS: The translation of the SBQ into Danish was validated as the results achieved were comparable to those reported from other studies and as acceptable sensitivity and specificity were observed. To avoid too many false positives, we recommend that the SBQD cut-off is set to ≥ 3 when screening preoperative patients and to ≥ 5 at primary physicians when screening high-risk patients. FUNDING: none. TRIAL REGISTRATION: not relevant.

Large laryngeal vascular malformation in a 5-year-old child.

A 5-year-old boy was admitted with stridor, which was initially interpreted as subglottic laryngitis. He had a history of prolonged hoarseness and his voice was deep for his age. The stridor persisted despite treatment with epinephrine inhalations and intravenous glucocorticoids. A direct laryngoscopy and blood work up did not support the suspected diagnosis. A MRI was then carried out, followed by angiography. The latter revealed an arteriovenous malformation (AVM) involving the lingual and superior thyroid arteries bilaterally. Owing to the rareness and extent of such an AVM, the patient was referred to Paris for further treatment. This case presents the difficulties in diagnostics and emphasises the importance of diagnostics and multidisciplinary approaches with regard to treatment of AVMs.

Outcome of cochlear implantation in children with cochlear malformations.

The objective of the study was the evaluation of outcomes of cochlear implantation (CI) in children with cochlear malformations. A retrospective case-control study was conducted in a tertiary referral centre. The patients were children with inner ear malformation judged by high-resolution computed tomography and magnetic resonance imaging treated with uni- or bilateral CI and a follow-up period of at least 3 years. They were matched with a control group of children operated for other reasons. The patients were operated by one of two surgeons using similar techniques including a standard perimodiolar electrode in all cases. The intervention was therapeutic and rehabilitative. The main outcome measures were category of auditory performance (CAP) and speech intelligibility rating (SIR). Eighteen children were diagnosed with cochlear malformations (12 % of children receiving CI). No statistical differences regarding CAP and SIR scores were found between the two groups. Only one child was diagnosed with a common cavity and performed below average. Children with auditory neuropathy performed beyond average. Children with cochlear malformations performed equally to children without malformation in the long term. Standard perimodiolar electrodes can be used despite cochlear malformations. The most important factors determining the outcome is the age of the child at the time of implantation and duration of hearing loss before CI. Awareness towards an increased risk of complications in case of inner ear malformations is recommended.

Cochlear implant after bacterial meningitis.

BACKGROUND: The aim of this retrospective case study at a tertiary referral center was to investigate the outcome of cochlear implantation (CI) in children with sensorineural hearing loss due to meningitis compared to CI in children with deafness due to other reasons. METHODS: This post-meningial group (PMG) consisted of 22 children undergoing CI due to deafness induced by meningitis, between December 1996 and January 2012. Five children had bilateral simultaneous implantation. None was excluded and the children were followed for at least 3 years. Operations were carried out by one of two surgeons using similar techniques in all cases. Each patient from the PMG was matched 2:1 with children having implantation for other reasons according to age and follow up (control group). RESULTS: Overall, the median category of auditory performance (CAP) and speech intelligibility rating (SIR) score were not statistically significantly different between the two groups. The presence of additional central nervous system (CNS) disorders (post-meningeal sequelae), however, correlated significantly with poorer outcome CONCLUSIONS: CI was a safe procedure without surgical complications in the present study. It is possible to restore auditory capacity and speech performance to a degree comparable to children undergoing implantation for other reasons. A statistically important variable is secondary CNS involvement. The rehabilitation program after CI should be adjusted according to these additional handicaps. It is recommended to screen meningitis patients as fast as possible to identify those with hearing loss and initiate treatment with hearing aids or CI.

[Spontaneous subcutaneous facial emphysema]. / Spontant subkutant facialt emfysem.

In this case we report how a previously healthy 35-year-old man developed a spontaneous monosymptomatic facial emphysema. The emphysema was found in large parts of deep and superficial compartments of the facial muscles, intraorbital to the optical nerve and along the blood vessels to the larynx level. The reason for this was never determined, but the differential diagnostics include allergic reaction, oesophagus/larynx rupture, infection, fracture of the facial bones, trauma or self-inflicted damage. The patient's symptoms receded over a course of four days to complete recovery.